EFFICACY OF EXTRACORPOREAL SHOCKWAVE THERAPY IN MANAGEMENT CHRONIC PATELLAR TENDINOPATHY IN ATHLETES

EFFICACY OF EXTRACORPOREAL SHOCKWAVE
THERAPY IN MANAGEMENT CHRONIC PATELLAR
TENDINOPATHY IN ATHLETES
Eslam M. Elkhalal* ; Ragia M. Kamel ** ;
Yasser M. Aneis*** and Mohamoud Abou Sayed****
*Demonstrator of Physical Therapy of Basic Science Department, Faculty of physical
therapy. Egyptian Chinese university.
** Professor Doctor of Physical Therapy of Basic Science Department, Faculty of
physical therapy. Cairo University.
*** Assistant Professor Doctor of Physical Therapy of Basic Science Department,
Faculty of physical therapy. Cairo University.
**** lecturer of orthopedic and spine surgery at kasr alainy medical school, Faculty of
Medicine, Cairo University.
*E-mail - eelkhalal@ecu.edu.eg
ABSTRACT
Background: There is no evidence-based, preferred treatment of choice
for patellar tendinopathy. patellar tendinopathy is an overuse syndrome
with pathologic changes.
Purpose: The purpose of this study is to determine the effectiveness of
ESWT in management Chronic Patellar Tendinopathy in Athletes.
Materials and methods: Thirty athletes of both sexes with chronic
patellar tendinopathy in the study, their age ranged from 14 to 26 years
old recruited randomly. They were randomly divided into two groups (A
& B). Study group (A) (15 patients) received 3 sessions per week for 6
weeks of ice packs and isometric exercises while group (B) (15 patients)
received shock wave therapy. All patients in both groups were measured
using the Victorian Institute of Sport Assessment (VISA) test and a
vertical jump test.
Results: There was no significant difference between the two groups
pretreatment (p > 0.05), while there was a significant increase in vertical
jump height of group B compared with that of group A (p = 0.001).
There was no significant difference between the two groups pretreatment
(p > 0.05), while there was a significant increase in VISA of group B
compared with that of group A (p = 0.0001) post treatment.
Conclusion: Extracorporeal shockwave treatment appeared to be
effective and safe in the management of patients with chronic patellar
tendinopathy. ESWT shoud be considered to be as a part of a treatment
protocol for patellar tendinopathy.
Keywords: extracorporeal shockwave; Victorian Institute of Sport
Assessment; patellar tendinopathy.
Egypt. J. of Appl. Sci., 36 (7-8) 2021 151-162
INTRODUCTION
Patellar Tendinopathy is an overuse injury to the knee extensor
mechanism caused by repeated mechanical stress from sports actions such
as jumping, landing, acceleration, deceleration, and cutting. (1)
During a single exercise session, micro-tearing of the knee extensor
tendons can occur as a result of the constant repetition of these movements
or as a result of insufficient recovery time in between sessions. The inferior
pole of the patella, where the patellar tendon inserts, is the component of the
knee extensor mechanism most likely to be impacted. The insertion of the
quadriceps tendon to the upper pole of the patella and the insertion of the
patellar tendon into the tibial tuberosity are two less commonly affected
areas of the knee. (1)
According to research, the incidence of patellar tendinopathy in elite
athletes is significantly higher than in recreational athletes. Patellar
tendinopathy can affect athletes of all ages, from adolescents to those in their
third decade and beyond. (2)
Patellar tendinopathy shares many of the same signs and symptoms as
other types of knee pathologies, such as pain when sitting for long periods of
time, squatting, or climbing stairs. Typically, when performing activities that
require the storage and release of energy in the patellar tendon, the amount
of load-related pain increases in proportion to the demand placed on the
knee extensors. When a load is applied, sudden tendon pain occurs, which
usually subsides almost immediately when the load is removed. When a
patient is resting, he or she is unlikely to experience pain. (1)
When it comes to jumper's knee, there is no evidence-based treatment
that is preferred over the others. The condition is also characterized by a
poor response to treatment, which frequently leads to the search for
alternative therapies by both health professionals and patients. (1)
In the early phases of the disease, most people with jumper's knee are
treated with medical and rehabilitation care. (3)
Early recognition and diagnosis of jumper's knee are critical because it
can have a long and painful progression. Although non-steroidal antiinflammatory
drugs (NSAIDs) have traditionally been used, they have
become less judicious in recent years as more physicians have realized that
the disease is not an inflammatory condition. As a result, it is possible that
nonsteroidal anti-inflammatory drugs (NSAIDs) will not provide significant
long-term benefit in tendinopathy. (4)
Patellar tendinopathy can be treated with Extracorporeal shock wave
therapy, which is both safe and effective. Waves are generated for ESWT by
accelerating a projectile through a tube at the end of which it strikes an
applicator that comes into contact with the skin, using compressed air as a
propellant. In order to account for this, there are significant differences
between the waves generated by each technology. The first difference is that
152 Egypt. J. of Appl. Sci., 36 (7-8) 2021
radial shockwaves have a more superficial effect because the maximum
energy is reached at the skin's surface, as opposed to focused shockwaves,
which reach a maximum energy in the focus that is located deeper within the
body tissues. (5)
It has also been demonstrated that pressure waves generated by ESWT
are, from a fundamental point of view, harmless. When it comes to physical
therapy clinics in the Netherlands, radial shockwave therapy (ESWT) is
used far more frequently (by a factor of four to one) than focused shockwave
therapy (FSWT). (6)
This could be due to the fact that these devices are more reasonably
priced than other options. There has not been a study to compare the
effectiveness of radial shock wave in the treatment of patellar tendinopathy,
so the objective of this study was to determine the effectiveness of ESWT in
management Chronic Patellar Tendinopathy in Athletes.
SUBJECT, MATERIALS AND METHODS
This study was carried out on 30 athletes with patellar
tendinopathy. This study was conducted in faculty of physical therapy
Egyptian Chinese University. Their age from 14 to 26 year. This study
was conducted from April 2020 to May 2021.
The criteria used to make the diagnosis of patellar tendinopathy
were Pain at the inferior pole of the knee with training, Tenderness at the
inferior pole of the patella with palpation, Absence of other knee
disorders, such as patellofemoral stress syndrome, each potential study
subject was screened to meet the following.
Inclusion criteria:
Age range of 14-26 years, Male and female, Diagnosis of patellar
tendinopathy as described above, History of patellar tendinopathy
for at least 3 months, Pain that was non-responsive to nonsteroidal
anti-inflammatory medication, Athlete’s basketball players and
volleyball players.
Exclusion criteria:
Receiving physiotherapy (eccentric loading/stretching, etc.) within
4 weeks of randomization visit, Receiving NSAIDs or
acetaminophen for any chronic condition within 1 week of
randomization visit, History or physical findings of lumbar disc
disease, compression syndrome, local arthrosis, or neurological
abnormality, Previous surgery for patellar
tendinopathy,Thrombopathy, infection, tumor, or other severe
systemic disease, Receiving systemic therapeutic
anticoagulation,Pregnancy,Previous ESWT treatment.
All subjects who were selected provided written informed consent
before entering the study. Subjects were randomly assigned to two
groups:
Egypt. J. of Appl. Sci., 36 (7-8) 2021 153
Group (A) Controlled group
 Consists of fifteen patellar tendinopathy subjects received 3 sessions
per Week for 6 weeks.
 Each session, subjects received Ice pack for 15 minutes and isometric
exercises 20 reptations for quadriceps femoris muscle. The patient was
asked to contract the muscle without lifting the heel. To check the
correct contraction of the muscle, the practitioner palpates the patella to
feel its proximal migration. A right knee is shown with the patient in
the supine position.
Group (B) Extracorporeal shockwave group
This group received Extracorporeal shock waves in addition to ice packs
and isometric exercises.
RADIAL shock wave
Fig.(1):
Product Name: radial shockwave therapy
Portable: portable
Application: salon, home, clinic
Theory: ultrasound
Type: shockwave therapy
Trademark: zesaybeauty
Specification: CE
Origin: China
HS Code: 90189090
Component projectile, screen
 Consists of fifteen patellar tendinopathy subjects received 3 sessions
per week for 6weeks.
154 Egypt. J. of Appl. Sci., 36 (7-8) 2021
Session was performed without anesthesia using a radial shock
wave device, which produces shock waves by a projectile, accelerated
with a pressurized air source, which strikes a 15 mm diameter metal
applicator. The energy produced is then transmitted to the skin as a
shock wave, through a standard, commercially available ultrasound
gel. The waves are dispersed radially from the application site to
surrounding tissues.
Each session consists of 2000 impulses at 8 Hz. The energy flux
density is 0.12 mJ/mm2 since this corresponds with 2.4 bar on the radial
shockwave generator of the used machine.
The procedure was performed with the patient crook lying
position after application of ultrasound gel on the skin overlying the
distal pole of the patella and patellar tendon. The shock waves were
directed from anterior to posterior. This is a dynamic process in which
the area of maximal tenderness is treated circumferentially, starting
from the most painful site. The average size of the treated area
measured 4–8 cm in width and 4–8 cm in length, and the time of
treatment ranged from 4 to 8 min.
There was a significant increase in vertical jump height and VISA
post treatment compared with pretreatment which is a good indicator of
increased muscle power and decreased pain in the patellar tendon.
Statistical analysis
Prior to analysis, the normality of data was checked using Shapiro-
Wilk test. Levene’s test for homogeneity of variances was conducted to test
the homogeneity between groups. Data were normally distributed and there
was homogeneity of variance. There were no outliers in the data as assessed
boxplot. Descriptive statistics and ANOVA test was conducted for
comparison of the subject characteristics between both groups. Chi squared
test were conducted for comparison of sex distribution between both groups.
Mixed MANOVA was conducted to compare the effect of time (pre versus
post) and the effect of treatment (between groups), as well as the interaction
between time and treatment on mean values of vertical jump height and
VISA. The level of significance for all statistical tests was set at p < 0.05.
Statistical analysis was performed through the statistical package for social
studies (SPSS) version 25 for windows.
RESULTS:
Participant characteristics:
Table 1 showed the participant characteristics of group A and B.
There was no significant difference in age, weight, height, and BMI
between the groups (p > 0.05). There was no significant difference in sex
distribution between groups (p = 0.79).
Egypt. J. of Appl. Sci., 36 (7-8) 2021 155
Table 1. Basic characteristics of participants.
Group A Group B p-value
Age, mean ± (SD), years 18.2 ± 2.04 18.93 ± 1.66 0.37
Weight, mean ± (SD), kg 77.73 ± 16.37 79.13 ± 13.51 0.93
Height, mean ± (SD), cm 178.2 ± 13.33 180.53 ± 11.6 0.79
BMI, mean ± (SD), kg/m² 24.2 ± 2.38 24.17 ± 2.48 0.97
Sex, n (%)
Females 8 (53%) 6 (40%)
0.76
Males 7 (47%) 9 (60%)
SD, standard deviation; p-value, level of significance
Effect of treatment on vertical jump height and VISA:
Mixed MANOVA revealed that there was a significant interaction
of treatment and time (F = 79.9, p = 0.001). There was a significant main
effect of time (F = 1308.47, p = 0.001). There was a significant main
effect of treatment (F = 28.11, p = 0.001). Table 2 showed descriptive
statistics of vertical jump height and VISA and the significant level of
comparison between groups as well as significant level of comparison
between before and after treatment in each group.
Within group comparison
There was a significant increase in vertical jump height and VISA
post treatment compared with pretreatment in the group A and B (p <
0.001).
Between group comparison
Between group comparison before treatment revealed a nonsignificant
difference in all parameters (p > 0.05).
Comparison between groups post treatment revealed a significant
increase in vertical jump height of group B compared with that of group
A (p = 0.001). (table 2).
There was a significant increase in VISA of group B compared
with that of group A (p = 0.001) post treatment.
Table 2. Mean salivary flow rate and VAS-XQ at pretreatment, post
I and post II of group A, B and C:
Group A Group B p-value
mean ± SD mean ± SD A vs B
Salivary flow rate
(ml/min)
Pretreatment 41.4 ± 3.98 41.6 ± 2.89 1
Post treatment 43.83 ± 4 50.73 ± 5.43 0.001
p = 0.001 p = 0.001
VAS-XQ
Pretreatment 47.33 ± 1.39 48 ± 1.51 0.76
Post treatment 52.1 ± 1.6 67.53 ± 2.26 0.001
p = 0.001 p = 0.001
SD, Standard deviation; p-value, Level of significance
156 Egypt. J. of Appl. Sci., 36 (7-8) 2021
Figure (2). Mean vertical jump height pre and post treatment of
group A, B.
Figure (3). Mean VISA pre and post treatment of group A, B
DISCUSSION
Patellar tendinopathy is a degenerative process of the patellar tendon
of unknown origin which is considered to be frequently difficult to be
managed successfully, different treatment strategies have been suggested for
management of patellar tendinopathy but due to the incomplete
understanding of the underlying pathology, it still unclear the proper
Egypt. J. of Appl. Sci., 36 (7-8) 2021 157
management of this big issue. The underlying pathology in patellar
tendinopathy is considered to be a failed healing response due to a
degenerative process resulting from excessive overload rather than a
prostaglandin-mediated inflammatory process. (7)
In our study we used Extracorporeal Shock Wave as a treatment
method for patellar tendinopathy which has a good indicator of the
improvement of muscle power and reduced pain in patellar tendon which is
in accordance with the study of (Pettrone F & McCall BR 2005) who
found significant differences between ESWT and placebo on pain.
(Lian et al.,2006) (7) has proposed that pain associated to patellar
tendinopathy is due to Neovascularisation which is found in patellar
tendinopathy, and it has been hypothesized that tendon pain is caused by
sensory nerves that grow into the tendon, causing a neurogenic
inflammation and pain. A further explanation of the pain in patellar
tendinopathy could be the disturbance of nociceptive transmission in the
nervous system by means of changed levels of substance P (SP), glutamate
and tyrosine hydroxylase (TH).
The most important finding in the present study is that SWT is safe
and effective treatment method, and provides significantly better results than
other conservative care including the Instrument assisted Soft tissue
mobilization even that the mechanism of the using of SWT in treatment of
patellar tendinopathy still not fully understood , animal studies has
demonstrated that ESWT may have an impact on the nociceptive
transmission in the nervous system and that it can cause dysfunction of
peripheral, sensory nerve fibers, resulting in pain relief as proposed by
(Chung Bet al.,2002) .(8)
Also, the study of (Collins et al.,2011) (9) had found a significant
difference in pain during activity in favor of the ESWT group. Which is in
accordance with the finding of our study in increasing the height of jump in
the Radial Shock Wave group.
ESWT is considered to be a modality for reducing pain and improving
function for patients with patellar tendinopathy that might be a dose
dependent effect. Based on a systematic review on the effectiveness of
extracorporeal shockwave therapy in common lower limb conditions, it was
concluded that ESWT-induced insignificant effects in pain scores, and
patient-rated pain reduction . (10)
Also had used extracorporeal shockwave to the distal rabbit femur
which had led to decrease in the concentration of substance P in the femoral
periosteum 6 weeks after shockwave application. These studies indicated
that shock wave may have selective effect on peripheral sensory
unmyelinated nerve fibers without affecting large, myelinated nerve fibers.
Which is going to decrees pain and preserving motor function of the muscle
preserving that the muscle activity so the end result will be decreasing
158 Egypt. J. of Appl. Sci., 36 (7-8) 2021
inflammation and having a good muscle power which is inconsistence with
the finding of our study.
It seems that there are two different explanations of the use of SWT in
the management of pain in patellar tendinopathy and there is flat
contradiction to the aforementioned theory about neurovascular structures
and pain. A possible explanation could be that, due to the improvement in
pain and function, patients became more active, resulting in increased
vascularity. In athletes the degree of neovascularization can also vary during
the season but no data on sport participation were given by Wang. (11) So,
in order to develop an effective ESWT treatment protocol for patellar
tendinopathy it should be clear that the exact pathophysiology of patellar
tendinopathy and to clarify the working mechanism of shockwaves on
pathological tendon tissue and neovascularization. (12)
The findings of our study confirms that Shock Wave has improved
VISA scores in the treated group significantly control group which is in
agreement in the study of(Peers KH et al.,2003) (13) who conducted by
Comparing outcomes of 13 patients undergoing management of patellar
tendinopathy treated with surgery to those of 14 patients treated with SWT,
there were significant improved VISA and VAS scores were observed in
both groups at 6-month follow-up, and the period of working inability was
of 6.1 weeks for the surgically treated group and 0 for the SWT group.
(Furia JP.,2006)(14) has evaluated the effects of a standardized, single
treatment, low-energy protocol of radial SWT on patients with chronic patellar
tendinopathy resistant to other conservative treatment and compared them with
control group. (Furia JP.,2006)(14) found that the SWT-treated group reported
significantly better mean of VAS and VISA scores at 1 month, 3 months, and
12 months from the treatment than the controls. Moreover, then the
improvement of the VAS and VISA, patients treated with radial SWT returned
to pre-injury sport activities by few months.
(Taunton et al., 2003)(15) had randomized clinical trial where the effects
of ESWT for patellar tendinopathy had been evaluated on two groups. A study
group of 10 received from three to five focused ESWT treatments with an
energy level of 0.17 mJ/mm2, where the control group of 10 patients had a
placebo treatment. Evaluation up to 12 weeks after the last treatment included
VISA score and a vertical jump test. The VISA score and vertical jump test
improved significantly in the study group compared to the control group. Which
is in agreement of the finding of our study in both variables (VISA score and a
vertical jump test) and also it could be inferred from that ESWT should be
considered important part of the rehabilitation process added to the traditional
tools used in management of patellar tendinopathy.
(Bosch et al., 2009)(16) suggested another explanation for the failed
treatment of ESWT in patellar tendinopathy is that athletes continued
participating in their usual training program during the treatment and follow-up
Egypt. J. of Appl. Sci., 36 (7-8) 2021 159
period and received no restrictions with regard to sports participation during the
season.
(Zwerver et al.,2010)(17) have reached to a finding that it is possible
that the total load on the tendon was too high leading to insufficient time for
recovery, the authors postulated that there was a combination of collagen
disorganization induced by ESWT and the mechanical load from training which
might be the cause of the reduced capacity of the reparative effects of ESWT.
The optimal treatment dose has not been established as the treatment
dose seems to depend on energy flex density and number of shocks. As
evident by the study of (Everhart et al., 2017)(18) who observed that a
significant effect of ESWT on pain reduction using energy flux density
between 0.17 – 0.25 mJ/mm2.
There is a considerable variability in the improvement of VISA scores
from shockwave therapy which may be related to an inverse relationship
between symptom improvement and total dose of treatments as suggested by
(Wang et al., 2007) (11) who stated that the best results could be achieved by
using an intermediate dose in a single session. While (Vetrano et al.,
2013)(19) had used low to intermediate dosing over 3 weekly sessions resulting
in only moderate results. which is in opposite with our findings of this study that
best results of VISA scores were achieved by low to intermediate dosing over 3
weekly. A possible explanation of the difference in the finding of our study
could be the age of the athletes which has a high influence of the regenerative
capacity in patellar tendinopathy. also, it could be inferred that the chronicity
plays an important role in the healing of the patellar tendinopathy in ESWT.
CONCLUSION & RECOMMENDATIONS
Extracorporeal shockwave treatment appeared to effective and safe in the
management of patients with chronic patellar tendinopathy. ESWT must be
considered to be as a part of a treatment protocol for patellar tendinopathy.
Shockwave should be considered to be an important treatment for chronic
patellar tendinopathy that have not responded to conservative measures and
physical therapy. We do not recommend it for acute conditions. The best results
are could be obtained when it used in combination with eccentric exercises and
standardized physical therapy protocols.
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تأثير الموجات التصادمية علي التهابات العضلة الرباعية في الرياضين
اسلام محمد الخلا ل ا رجية محمد اامل ياسر محمد ايي محمود ابوسيد
* معيد قسم العموم الاساسيه ، کمية العلاج الطبيعي ، جامعة المصرية الصينية .
** استاذ قسم العموم الاساسيه ، کمية العلاج الطبيعي ، جامعة القاهرة.
*** استاذ مساعد قسم العموم الاساسيه ، کمية العلاج الطبيعي ، جامعة القاهرة.
**** مدرس العظام وج ا رحتها ، کمية الطب، جامعة القاهرة.
يبذه مختصره
الخلفية: لا يوجد علاج مفضل قائم عمى الأدلة لعلاج التهابات العضمة الرباعية. التهابات العضمة الرباعية هو
متلازمة الإف ا رط مع التغي ا رت المرضية.
. الهدف: تحديد تاثير الموجات التصادمية عمي التهابات العضمة الرباعية في الرياضيين.
المواد والأساليب:ثلاثون رياضيًا من کلا الجنسين يعانون من التهابات العضمة الرباعية المزمن في الد ا رسة ،
ت ا روحت أعمارهم بين 41 و 62 عامًا تم تجنيدهم بشکل عشوائي. تم تقسيمهم بشکل عشوائي إلى مجموعتين )أ ،
ب(. تمقت مجموعة الد ا رسة )أ( ) 41 مريضًا( 3 جمسات في الأسبوع لمدة 2 أسابيع من أکياس الثمج وتمارين
متساوية القياس بينما تمقت المجموعة )ب( ) 41 مريضًا( علاجًا بموجات الصدمة. تم قياس جميع المرضى في
کلا المجموعتين باستخدام اختبار المعهد الفيکتوري لتقييم الرياضة واختبار القفز العمودي.
النتائج: لم يکن هناک فرق معنوي بين المجموعتين، بينما کانت هناک زيادة معنوية في ارتفاع القفز العمودي
لممجموعة)ب( مقارنة مع المجموعة )أ(
لم يکن هناک فرق معنوي بين المعالجة المسبقة لممجموعتين، بينما کانت هناک زيادة معنوية في تأشي ا رت
المجموعة)ب( مقارنة بالمجموعة)أ( بعد العلاج.
الخلاصه : يبدو أن العلاج بالموجات الصدمية خارج الجسم فعال وآمن في إدارة المرضى الذين يعانون من
التهابات العضمة الرباعية. يجب اعتبا ا رلموجات التصادمية کجزء من بروتوکول علاج التهابات العضمة الرباعية .
الالمات الداله: صدمة خارج الجسم. المعهد الفيکتوري لتقييم الرياضة ؛ اعتلال الوتر الرضفي.
162 Egypt. J. of Appl. Sci., 36 (7-8) 2021